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Non-Member: Preliminary Consultation Questions
Respondent Information
1.
Contact
First Name
Last Name
Email Address
Phone Number
2.
I am a
Medical Student
Resident
Staff Physician
Other (please specify)
3.
Gender
Female
Male
Gender Diverse
Prefer not to disclose
4.
Which race category best describes you? Check all that apply:
Black (African, Afro-Caribbean, African Canadian descent)
East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese descent or Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian descent
Indigenous (First Nations, Métis, Inuk/Inuit)
Latino (Latin American / Hispanic descent)
Middle Eastern (Arab, Persian, West Asian descent (e.g., Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)
South Asian South Asian descent (e.g., East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)
White European descent
Another race category (Includes values not described above or Do not know, not applicable, prefer not to answer)
5.
Province or Territory of Practice (select all that apply)
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Northwest Territories
Nunavut
I practice outside of Canada
6.
If you are a staff physician, how many years have you been practicing
1-5
6-15
16-25
25+
7.
Certification/training stream
CCFP
CCFP(EM)
FRCPC
Other (please specify)
8.
Location of practice (select all that apply)
Urban Community
Urban Academic
Rural, Remote or Small Urban (population less than 30,000 people)
9.
Type of practice (i.e. in your practice location what is the scope of your practice)
10.
I am not currently a CAEP member because:
11.
I would like to
join/renew
with CAEP:
Yes
No
Email to contact:
12.
I would like to participate in an interview style consultation
Yes
No
